While the prevalence of mental illness is similar between rural and urban residents, the services available are
very different. Mental healthcare needs are not met in many rural communities across the country because
adequate services are not present. Providing mental health services can be challenging in rural areas. According
to WICHE's Rural Mental
Health: Challenges and Opportunities Caring for the Country, the following factors are particular
challenges to the provision of mental health services in rural communities:

Accessibility – Rural residents often travel long distances to receive services, are
less likely to be insured for mental health services, and are less likely to recognize an illness.

Acceptability – The stigma of needing or receiving mental healthcare and fewer
choices of trained professionals who work in rural areas create barriers to care.

This topic guide focuses on mental health in rural areas and helps health and human services providers in their
efforts to develop, maintain, and expand mental health services in rural communities. It also highlights
challenges and important issues in mental healthcare delivery, such as workforce shortages, access issues,
anonymity, stigma, integration of mental health services into primary care, and suicide prevention. Information
regarding substance use disorder (SUD) can be found in RHIhub's Substance Abuse in Rural Areas topic guide.

The data for these topics are available by age, geographic characteristics and socioeconomic characteristics.
The
geographic characteristics are detailed by geographic region of the U.S. and county type. County type is divided
into population data classes:

To further complicate the challenges of providing mental health services, the most disadvantaged and
under-resourced communities are often those with the most severe need for mental healthcare providers. County-Level Estimates of
Mental Health Professional Shortage in the United States reports that higher levels of unmet need for
mental health professionals exist in counties that were more rural and had lower income levels.

As of September 4, 2018, HRSA had designated 2,672 mental health professional shortage areas in rural areas. It
is estimated that it would take 1,851 practitioners to remove the designations. For the most current figures,
see HRSA's Designated
HPSA Statistics.

This map identifies nonmetro HPSAs based on November 2017 data.HRSA.gov data:

What other challenges affect access and the provision of mental health services in rural areas?

Travel distance, lack of public transportation, and uninsurance are commonly identified as challenges to
accessing healthcare in rural areas. Reimbursement issues and the social stigma of needing mental health
services are also identified as significant challenges that affect access and the provision of mental health
services in rural areas.

Reimbursement

The reimbursement offered by payers such as Medicaid, Medicare, and private insurers has a significant impact on
the ability of rural providers to offer mental health services. The publication Encouraging
Rural Health Clinics to Provide Mental Health Services: What are the Options? notes that Rural Health
Clinics may be reluctant to start providing mental health services when reimbursement rates are low. In
addition, high no-show rates among mental health clients and high numbers of uninsured patients further
exacerbate the issue of low reimbursement rates paid by Medicaid and others.

Providing mental health services via telehealth, sometimes referred to as telemental health or telebehavioral
health, has shown promise in helping to alleviate the lack of mental health services in rural areas. However,
reimbursement is also a challenge for telehealth services. For additional information about telehealth services
and associated reimbursement issues see RHIhub's Telehealth Use in Rural
Healthcare topic guide.

Stigma

Nearly 1 in 5 adults in the U.S. experiences a mental disorder within any given year according to the National Alliance on
Mental Illness. Yet, the misconceptions, myths, and cultural stigma associated with mental illness are
significant barriers that keep people with mental disorders from seeking and receiving treatment in rural areas.
Factors that may influence rural residents to avoid seeking care include such issues as:

Lack of understanding and knowledge of mental illness, sometimes even among healthcare staff

Prejudice or stigma towards people with mental health disorders, often based on fear and unease

Secrecy about mental illness in the community and general hesitancy to seek care

Perception of a lack of confidentiality and privacy in small towns with closely-tied social networks

While there are drawbacks to small communities when it comes to mental health, there are positives as well. The
close-knit nature of rural communities can also mean that residents are more likely to rally around each other
and provide community support in times of need. This strong external support group can help facilitate a
person's success in treatment and also help support the family's efforts in attending to the care seeker.

What can a rural community or healthcare facility do to minimize the challenges of accessing and providing
mental health services in a rural area?

There are several approaches that can be tried in rural communities to minimize the challenges of providing
mental health services and expanding the mental health workforce. Some of the most commonly used practices to
deal with workforce issues include:

Expanding the use of telemental health services

Offering loan repayment programs and state tax waivers

Providing clinical rotations in a rural setting to grow-your-own workforce

Another approach to improving access and providing mental health services is the School-Based Health Center
(SBHC) model for children in rural areas. SBHCs work with the school and community to improve children's mental
health by providing onsite healthcare services delivered by an interdisciplinary team of primary care and mental
health clinicians. Services may range from wellness exams to mental health services. SBHCs can screen children
for mental, behavioral, or developmental disorders (MBDDs) including anxiety, depression, social skills, and
attention-deficit/hyperactivity disorder (ADHD). In addition, SBHCs can provide customized care for children
with special needs who may be at a higher risk for MBDDs by monitoring medication and assisting in developing
Individualized Education Plans (IEPs).

In addition, education and awareness efforts targeted toward rural residents have been used to increase
familiarity and comfort with mental health issues. An example of this is the Mental
Health First Aid public education program. This program helps laypeople identify, understand (and
thereby reduce the stigma), and respond to signs of mental illnesses and substance use disorders.

What are some of the benefits of integration of mental health services into primary care in a rural
community?

In recent years, health policy experts and healthcare providers have begun to encourage closer integration
of mental or behavioral health and primary care services. It is assumed that integration will
increase access to mental healthcare services, particularly in rural communities, as well as increase quality of
care through enhanced coordination of services. In rural areas, where behavioral health workers and primary care
providers are in short supply, integration is vitally important. Integration of these services is an effective
strategy for maximizing the use of scarce rural healthcare resources and improving the quality of care for both
behavioral health and primary care patients.

Numerous studies, including this 2010
Maine Rural Health Research Center report, have shown that patients in rural areas who need mental
health services typically see their primary care provider first. Often it is the primary care provider who
initially diagnoses the need for mental health services. In addition, a high percentage of mental healthcare for
rural patients is already provided by primary care providers, so integrating the services of a mental healthcare
provider into the primary care setting can expand on what is already being done. Efficiency of service and ease
of use also create a level of coordinated care and access that benefits both the patient and the provider.

The integration, or even the co-location, of mental health services with primary care services
can also help to reduce or eliminate the effects of the powerful social stigma associated with mental illness in
many rural areas. Social stigma prevents many rural citizens from obtaining needed services, but it is less of a
deterrent when behavioral health professionals see patients in primary care settings. The integration of
behavioral health and primary care services also reduces the challenge of maintaining anonymity. Rural patients
may be reluctant to be seen in settings where their privacy might be compromised but more willing to seek mental
healthcare from the more common and accepted primary care clinic. Primary Care, Behavioral Health, Provider
Colocation, and Rurality discusses how co-location, although different from integration, offers the
potential of future collaboration with primary care providers, as well as opportunities for care coordination.

Is there a resource for rural primary care providers and other healthcare professionals that can connect
patients to mental health services and treatment?

When there are few resources to provide direct mental health services in a community, local healthcare
professionals may need to refer patients to facilities outside of the community. The Substance Abuse and Mental
Health Services Administration (SAMHSA) maintains the National
Directory of Mental Health Treatment Facilities 2018, an online listing of federal, state and local
government, and private facilities that provide mental health treatment services.

Where can rural veterans and rural healthcare providers assisting veterans find information about mental health
services in their rural areas?

Rural healthcare providers and veterans can find information about mental health services for veterans in their
area by contacting either their closest VA medical center or community-based outpatient clinic (CBOC). To access
contact information, go to the
VA Locations tool and choose a state to
access a list of CBOCs, VA Medical Centers, and Vet Centers. See the
VA Mental Health
website for a broad overview of mental health programs available to veterans. Additional information can
be found in the
Guide to VA
Mental
Health Services for Veterans & Families.

According to a 2015 MMWR QuickStats
article,
from 2004 and 2013, micropolitan and rural counties experienced an approximately 20%
increase while the large central metropolitan counties displayed a 7% increase. In 2013, the suicide rate in
rural counties was 17.6 deaths per 100,000 compared with large central metropolitan counties at 10.3 deaths per
100,000.

Additional information regarding the impact of suicide in rural communities can be found in Understanding
the Impact of Suicide in Rural America. This policy brief developed by the National Advisory Committee
on Rural Health and Human Services (NACRHHS) also discusses prevention strategies available at the state and
national level and provides recommendations to the Department of Health and Human Services urging it to focus
more explicitly on emphasizing and including the rural dimensions of suicide into their programs, research,
and outreach to address existing knowledge gaps and strengthen the evidence base.

How can our community take action to prevent suicides?

The Suicide Prevention Resource Center (SPRC) is a premiere source of
information on the topic of suicide prevention. The following resources and tools can be helpful to rural
communities working on suicide prevention efforts:

States and Communities – Find out what your state is doing to
prevent suicide. Includes state suicide prevention plans, state data, and how to contact people involved in
suicide prevention in your state.

You can also contact the Suicide Prevention Resource Center for
assistance. SPRC can connect you with people, organizations, and resources in your rural community, state and
nationally and provide technical assistance and training on suicide prevention.

What resources are available for suicide prevention efforts?

The U.S. Department of Health and Human Services (HHS) considers suicide a significant public health problem and
is involved in prevention activities. Several federal agencies collaborate and direct necessary prevention
resources, services, and programs that are both public and private. Federal resources on suicide prevention
include:

How can our school take action to prevent suicides?

According to the Centers
for Disease Control and Prevention, suicide is the second leading cause of death among youth (ages
10-24) in America. Rural schools can play an important role in preventing suicide among rural youth by:

Becoming involved with your state or community's suicide prevention coalition and learn how to coordinate
your school's efforts with state or community efforts.

The Rural Health Information Hub is supported by the Health Resources
and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
under Grant Number U56RH05539 (Rural Assistance Center for Federal Office of Rural Health
Policy Cooperative Agreement). Any information, content, or conclusions on this website are
those of the authors and should not be construed as the official position or policy of, nor
should any endorsements be inferred by HRSA, HHS or the U.S. Government.